Wednesday, December 1, 2010

Finally Wrong-site Surgeon Speaks Out

Everyday there is news about medical errors, with the most recent being the OIG report on Medicare Adverse Events published this week that stated that Medicare beneficiaries experienced adverse events that contributed to at least 15,000 deaths in a single month.  As I was reading this report I sat back and wanted to cry for our patients and for our care givers, and am saddened each and every time I read about these events that occur so often.  I then ask myself, “What do we need to do to fix this problem”?

Tuesday, I was doing a marketing video/photo shoot for my business school, Loyola University Chicago.  For this video shoot, I had to sit down with the staff and engage in a spontaneous meeting of some kind.   I took this opportunity to tell them what I do in my profession, Lean Healthcare, and discussed with them the reality, facts and figures of the errors that occur in our hospitals. I expressed my passion around patient safety and how hospitals can improve patient care. 

As part of the photo shoot, I had to speak to a small group about any topic of choice.  They were interested in the discussion started earlier. So I began talking about the blog that I was going to write about Dr. Ring who performed a wrong-site wrong procedure surgery, and published this case study in latest issue of The New England Journal of Medicine.

I applaud and commend Dr. Ring for his courage to put forth the detailed account of the events surrounding this error.  I have deep compassion for anyone in this scenario knowing that this error is a result of a broken system which allows this to happen, not the person. Dr Ring published this with the intent of helping others not to make the same mistake.  

This is what I hope is the beginning of physicians coming forward without fear to reveal the circumstances surrounding any adverse events. This is a monumental step moving forward to help improve our situation in healthcare.  It is significant that this event was disclosed by a physician whose support is critical in creating a culture of safety.   There is absolutely no way we can begin to correct any flaw in the system without the detailed knowledge on how this occurred.  

With his account of the event, it became evident that there were several system failures that existed to allow this type of error to happen. The circumstances around this mistake highlight the confusion, lack of and/or the practice of standards, miscommunication and general chaos that surrounds the environment in which care is being provided on a daily basis. I believe that Dr. Ring began the culture change to make patient safety a top priority in his organization.  Dr Ring wants this to be a learning experience for others so they do not have to go through something like this. 

As part of the lessons learned from this event there was a renewed emphasis and belief in the importance of the Patient Safety Standards set forth by the Joint Commission. The sharing of information and experiences is something we can all learn from. In light of the continued number of surgical errors, I would recommend that other organizations perform FEMA’s around this process. This ultimately should prevent other patients from harm.  

Before I spoke with the groups, they did not have an understanding of where our country is with healthcare care mistakes. After I told them the story about Dr. Ring and the publication of his mistake, they told me how thankful they were that he was brave enough to put the safety of patients first to help prevent errors and not let possible litigation stand in his way.